"No Papers, No Treatment": a scoping review of challenges faced by undocumented immigrants in accessing emergency healthcare

Background Undocumented immigrants face many obstacles in accessing emergency healthcare. Legal uncertainties, economic constraints, language differences, and cultural disparities lead to delayed medical care and thereby exacerbate health inequities. Addressing the healthcare needs of this vulnerable group is crucial for both humanitarian and public health reasons. Comprehensive strategies are needed to ensure equitable health outcomes. Objective This study aimed to identify and analyze the barriers undocumented immigrants face in accessing emergency healthcare services and the consequences on health outcomes. Methods We used a scoping review methodology that adhered to established frameworks. Utilizing MEDLINE/PubMed, Embase, Web of Science, PsychoInfo, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), we identified 153 studies of which 12 focused on the specific challenges that undocumented immigrants encounter when accessing emergency healthcare services based on the inclusion and exclusion criteria. Results The results show that undocumented immigrants encounter significant barriers to emergency healthcare, including legal, financial, linguistic, and cultural challenges. Key findings were the extensive use of emergency departments as primary care due to lack of insurance and knowledge of alternatives, challenges faced by health professionals in providing care to undocumented migrants, increased hospitalizations due to severe symptoms and lack of healthcare access among undocumented patients, and differences in emergency department utilization between irregular migrants and citizens. The findings also serve as a call for enhanced healthcare accessibility and the dismantling of existing barriers to mitigate the adverse effects on undocumented immigrants' health outcomes. Conclusions Undocumented immigrants' barriers to emergency healthcare services are complex and multifaceted and therefore require multifaceted solutions. Policy reforms, increased healthcare provider awareness, and community-based interventions are crucial for improving access and outcomes for this vulnerable population. Further research should focus on evaluating the effectiveness of these interventions and exploring the broader implications of healthcare access disparities.


Introduction
People who live without legal authorization in a foreign country form a significant global demographic [1].The terms "immigrant" and "migrant" are often used interchangeably in this context; however, "immigrant" typically refers to individuals who move to another country with the intention of permanent settlement, whereas "migrant" can refer to those who move temporarily, often for work, and may not intend to stay permanently [2].Estimates suggest there are approximately 281 million international migrants worldwide, a substantial portion of whom lack legal status in their host countries [3].For instance, in the United States alone, it is estimated that there are around 10.5 million undocumented immigrants, representing about 3.2% of the total U.S. population [4].Similarly, in the European Union, there are an estimated 3.9 to 4.8 million undocumented migrants [5].These individuals face many obstacles in accessing healthcare.Such obstacles include lack of health insurance, fear of deportation, ineligibility for government programs, and language and cultural differences [1,[6][7][8][9][10][11][12][13][14].Addressing their healthcare needs is crucial not only from a humanitarian perspective but also for public health, as their exclusion from healthcare systems has serious consequences [15,16].
Studies found that financial barriers to healthcare included high out-of-pocket payments, high service prices, fragmented financial support, limited funding capacity, fear of deportation, and delayed referral [12,17].Geographic challenges also play a role, with many migrants living in areas where healthcare facilities are either overwhelmed or scarce.These barriers hinder not only access to routine care but also emergency services, contributing to wider public health concerns [7,12,[17][18][19].
In emergency care situations, undocumented immigrants face even greater challenges.They often avoid essential treatment due to financial problems and fear of legal actions [1,6,10,12,17,18].Even when they do seek emergency care, they often encounter language and cultural differences that can lead to misunderstandings and inappropriate treatment [7,12].This avoidance of essential care not only endangers their health but also affects the health of the community [10,11,13].
Although extensive searches were conducted, no systematic reviews were found that specifically addressed the difficulties undocumented immigrants have in accessing emergency care.The phrase "No Papers, No Treatment," used in the title of this study, reflects the harsh reality that undocumented immigrants often face when seeking healthcare.This phrase, which has been echoed in various advocacy platforms and public discussions, encapsulates the severe barriers to care that this population experiences.This scoping review aims to bridge this gap by examining those very challenges.The objectives of this review are threefold: 1) to identify the specific barriers encountered; 2) to understand the reported consequences of these barriers on undocumented immigrants; and 3) to examine the solutions that have been proposed to improve their access to emergency care.By undertaking this study, we aim to provide a foundational understanding of the complexities involved in access to emergency healthcare for undocumented immigrants, thereby contributing to the body of knowledge and suggesting pathways for future research and policy development.This is the first study to address this neglected issue in healthcare research and policy.

Methodology
This scoping review was designed by integrating the methodologies described by Arksey and O'Malley (2005) [20] and further refined by Levac et al. (2010) [21].The research team consisted of two reviewers, who are also the authors of this work.These reviewers formulated the main research objectives and outlined the review by defining the search terms, identifying the databases for the literature search, and establishing the inclusion and exclusion criteria.We selected the MEDLINE/PubMed, Embase, Web of Science, PsychoInfo, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases due to their extensive coverage of medical, psychological, and health literature.The search terms were chosen to cover a wide array of relevant components ("emergency" OR "emergency care") AND ("undocumented immigrants" OR "illegal immigrants" OR "unauthorized immigrants" OR "undocumented migrants" OR "irregular migrants").This ensured the inclusion of literature that specifically addressed barriers faced by undocumented immigrants in accessing emergency care.
The search and selection processes were conducted by both reviewers.Duplicates were removed, followed by two parallel and separate screenings of titles and abstracts by each reviewer.The full-text review and data extraction were also performed independently by each reviewer, with any disagreements resolved through discussion.Our scoping review did not include a formal quality assessment of the included studies, in line with Arksey & O'Malley's (2005) [20] recommendations for scoping reviews.We limited our review to peerreviewed research articles that examined undocumented immigrants' barriers to emergency care and were published in English up to February 29, 2024.Studies were excluded if they did not focus on undocumented immigrants in accessing emergency care, were not related to undocumented immigrants, were not based on empirical research, or were published in languages other than English.This extensive selection process resulted in a total of 12 studies for the final review (Fig. 1).
All findings were entered in EndNote (version 21).The data from the included studies, which related to characteristics such as author, publication year, study design and participants, sample size, study purpose, and key findings were extracted and charted by the first author in Excel to address the research objectives.
Key findings were the excessive use of emergency departments for primary care due to lack of insurance and knowledge of alternatives [22], challenges faced by health professionals in providing care to undocumented migrants [9], increased hospitalizations due to severe Fig. 1 PRISMA symptoms, and lack of healthcare access [10,23], and differences in emergency department utilization between irregular migrants and citizens [19] (Table 1).

Barriers to accessing emergency healthcare
Barriers to accessing emergency care were broadly categorized under six themes: linguistic, financial, legal, cultural, health literacy, and other (Table 2).
Most of the legal barriers were related to one's undocumented status and lack of entitlements, such as a health insurance card or identity number [9,10,15,16,19,22,23,25,26].Fear of being reported to authorities [13,22,24] was mentioned in three studies.Administrative hurdles and systemic healthcare challenges, which include complications due to lack of proper documentation or previous medical records and the inefficiencies within the healthcare system itself, were also reported [9,15,26].
Transportation issues and lack of childcare were among the other barriers that prevented timely access to emergency healthcare [18].Geographical remoteness and the complexity of health insurance systems [10], the patchwork system of safety net care (which is especially relevant to emergency renal disease care and the inconsistency in healthcare policies) [23], and structural vulnerabilities such as poor working and living conditions [15,26], were other assorted factors affecting the migrants' accessibility and utilization of healthcare services.

Consequences of barriers
The costs of these identified barriers were increased reliance on emergency departments as primary care sources, higher rates of unfunded visits, and delays in treatment [22]; unintended pregnancies, delayed prenatal care, increased exposure to violence during pregnancy [25]; and limited access resulting in neglect of preventive care and excessive emergency service use [13,18].The researchers also identified disparities such as: unequal access to primary care, delayed treatment, and administrative burdens [9]; fears leading to delayed healthcare access and higher emergency severity [24]; extended emergency department stays and lower hospitalization rates for non-severe conditions [19]; substandard antenatal care and related risks [15,26]; more severe conditions upon hospital arrival and higher hospitalization rates [10]; and specific issues such as increased emergent dialysis usage and associated costs [23] (Table 3).

Suggested solutions
The studies advocate for systemic changes to improve healthcare accessibility and quality for undocumented immigrants.Free or low-cost services and culturally appropriate education [25], increased social and economic resources [13], information dissemination through trusted sources [18], legal clarification and language support [9], patient education about confidentiality and health rights [24], initiatives to better healthcare access for undocumented migrants and affordable insurance options [10], and inclusive Medicaid policies [23] were all recommended.Furthermore, comprehensive care that addresses health, social, and emotional aspects, with culturally adapted and coordinated approaches, were also suggested [16,19] (Table 3).

Research gaps and future directions
The studies identified several significant gaps and future research needs in healthcare access for undocumented immigrants.These include understanding the impacts of legislative measures [22], access to care without documentation [13,25], improving prenatal care, variations in emergency room use, effects of information sources, and structural impacts on healthcare-seeking behaviors [18].Other urgent areas for research are the impact of fear on healthcare access, ensuring understanding of a patient's rights and confidentiality, exploring health needs in regions with significant migrant populations, understanding intersections of immigration status with ethnicity in care disparities, and focusing on healthcare access and community care strategies for migrants [9,19,23].Finally, investigating comprehensive care pathways, uncovering structural vulnerabilities that affect health coverage, and developing enhanced protocols for vulnerable migrant populations are imperative for future healthcare improvement and policy development [10,24] (Table 3).Additionally, there is a notable lack of qualitative insight from undocumented immigrants/migrants themselves regarding their experiences and perspectives on accessing emergency healthcare.Future research should prioritize capturing these first-hand accounts to better understand the nuanced challenges faced by this population and to inform more effective and empathetic policy interventions.

Discussion
This scoping review aimed to identify and synthesize research on the challenges faced by undocumented immigrants in accessing emergency healthcare.The objectives were to identify specific barriers to care, understand   the consequences of those barriers, and explore proposed solutions to improve access.Despite differences in methodologies, participants, and regional focus, the studies highlighted the urgent need for systemic reform to improve healthcare accessibility for undocumented populations.

Barriers to accessing emergency care
Ensuring equitable access to safe, well-organized, and high-quality emergency care services for all individuals in need can help mitigate health disparities [27].However, several barriers were found that prevent undocumented immigrants from accessing emergency care.Most significantly, the fear of deportation led immigrants to avoid healthcare facilities [23,24].Asch et al. found that individuals who feared seeing a doctor lest they get reported to the immigration authorities were nearly four times more prone to delaying care for over two months, increasing the risk of disease transmission [28].Brenner et al. noted that deportation fears forced undocumented immigrants with end-stage renal disease (ESRD) to seek emergency care only when their condition became lifethreatening [29].
Cultural and linguistic barriers further complicate these challenges.Many immigrants rely on social media or friends for health information due to a lack of trust in healthcare systems [24].Granero-Molina et al. [30] note that health providers struggle to provide care due to language barriers and cultural misunderstandings [30].Additionally, transportation issues, childcare responsibilities, and systemic inefficiencies hinder timely access to care, particularly in emergencies [15,18,26].
Structural vulnerabilities also play a role, as immigrants often live and work in environments that limit their access to healthcare [15,26].DuBard and Massing emphasize that healthcare access for undocumented immigrants is further impeded by the complexity of health insurance systems [31].These systemic barriers result in a system where undocumented immigrants rely on emergency departments, leading to overcrowding and increased costs [22,23].Hsia and Gil-González note that legal ambiguities and administrative barriers exacerbate challenges in providing consistent healthcare access to undocumented immigrants [32].

Consequences of barriers
Barriers to emergency care have many consequences for undocumented immigrants.Relying on emergency departments for primary care leads to delays in treatment, worsening conditions, and higher hospitalization rates [10,22].Pregnant and undocumented women risk delayed prenatal care and exposure to violence [15,25,26].Limited access to primary care results in untreated conditions becoming acute emergencies [19].For patients with chronic conditions such as ESRD, limited access to regular hemodialysis forces them to rely on emergency departments for emergency-only hemodialysis EOHD, resulting in higher morbidity, mortality, and costs [23,33].Patients receiving EOHD often experience severe symptoms such as hyperkalemia and uremia before seeking emergency care [34].Clinicians providing EOHD also report significant morale distress due to the substandard care they have to provide [33,35].In addition, cultural barriers during emergency triage contribute to inadequate care for undocumented immigrants, particularly those arriving by small boats in Europe [30].Although our study did not specifically examine mental health conditions, it is well-documented that undocumented immigrants frequently experience significant mental health challenges due to the stress of living in uncertain conditions.This is particularly concerning in emergency department settings, where overcrowding and limited resources often result in inadequate mental health care for this vulnerable population.

Proposed solutions
Addressing these challenges requires systemic improvements to healthcare access and quality for undocumented immigrants.Cervantes et al. [34] argue that enhancing access to primary and preventive care through free or low-cost services and culturally appropriate education can help reduce the reliance on emergency departments for non-emergency conditions [34].Nandi et al. (2008) [13]emphasized the need for increased social and economic resources.
Legal clarification and policy changes that explicitly include undocumented immigrants in healthcare systems are essential.Improved access to primary care, coupled with patient education about their rights and the confidentiality of healthcare services, can alleviate fears related to immigration status [9,24].Affordable health insurance options and inclusive Medicaid (a joint federal and state program in the United States that provides health coverage to eligible low-income individuals and families) policies would significantly improve access to care and reduce the financial burden on safety-net programs [10,23].Brenner et al. (2021) [29] argue that systemic efforts to improve public health, reduce the effects of injury and illness, and secure access to emergency and basic health care for all must involve policies that prioritize care over immigration enforcement.
Programs that enhance access to primary care and consider broader inclusion policies can improve outcomes for undocumented immigrants [19].The inclusion of diverse healthcare provider perspectives, such as those of nurses, as seen in Jiménez-Lasserrotte et al.
(2023), is crucial for developing comprehensive care strategies that address the unique needs of undocumented populations.Addressing structural vulnerabilities, including working and living conditions, is essential for improving healthcare access and quality.Accessible antenatal care and comprehensive healthcare that addresses physical, social, and emotional needs are crucial for vulnerable populations [16].Addressing legislative barriers and reducing administrative burdens, as highlighted by the challenges faced in Spain, is also essential for ensuring equitable healthcare access [32].By focusing on these systemic changes, healthcare systems can better accommodate the needs of undocumented immigrants, ensuring they receive the necessary care without unnecessary legal and administrative obstacles.Cultural mediation can help to bridge gaps in understanding between healthcare providers and undocumented immigrants [30].

Research gaps and future directions
Significant research gaps remain in understanding the full extent of healthcare challenges faced by undocumented immigrants.Further research is needed to understand the impact of legislative measures on healthcare access [22].Additionally, studies should explore the influence of one's undocumented status on healthcare access and outcomes, especially in prenatal care [13,25].Comprehensive studies on emergency room use, information sources, and structural barriers to healthcare are needed [18].
More comprehensive studies on healthcare access and quality for undocumented immigrants are required to inform effective policies [9].Addressing the impact of fear on healthcare access, along with strategies to ensure that immigrants understand their rights, is critical [24].Research should focus on developing effective community care strategies to overcome healthcare barriers for migrant populations [19].Understanding the structural vulnerabilities affecting health coverage is imperative for future care improvement and policy development [15,26].Further research should also explore the impact of administrative barriers and the challenges of policy implementation, as seen in Spain, to develop more effective solutions [32].Additionally, research should prioritize examining the mental health challenges faced by undocumented immigrants, particularly in emergency settings.Given the limited resources in emergency departments, there is a critical need for targeted interventions that address these mental health needs to improve care and outcomes for this population.

Limitations
This review has several limitations.First, a restriction to English-language publications may have excluded important studies published in other languages and limited the global representativeness of our findings.Second, the exclusion of gray literature sources, such as reports and conference abstracts, may have overlooked valuable insights, restricting the breadth and depth of our review.Third, the heterogeneous methodologies employed across included studies introduced variability and could have complicated direct comparison and synthesis of findings.These limitations emphasize the need for careful interpretation and draw attention to areas where methodological improvements are needed in future research.

Conclusion
In conclusion, this comprehensive review found a diverse range of barriers faced by undocumented immigrants in accessing emergency healthcare services.Legal, financial, linguistic, cultural, and systemic factors collectively contribute to adverse health outcomes and strain emergency healthcare systems.Proposed solutions encompass policy initiatives such as enacting inclusive healthcare policies, together with community-based interventions like culturally tailored education and improved information dissemination.Further research is needed to understand the intersectionality of barriers, evaluate the effectiveness of proposed interventions, and assess the impact of legislative measures on healthcare access.By dismantling structural barriers, fostering cultural competency, and prioritizing the healthcare needs of undocumented immigrants, policymakers and practitioners can advance health equity agendas and foster a more inclusive healthcare landscape.Overall, addressing the diverse barriers to emergency healthcare access for undocumented immigrants is crucial for promoting health equity and improving public health outcomes.We will only achieve a truly healthy society when all its members, documented and otherwise, receive the care they need and deserve.

Table 1
Summary of included studies

Table 2
Barriers to accessing emergency care NS Not specified

Table 3
Consequences of barriers, solutions, and future research directions